Over the past two years, the Planning Exchange has examined structural challenges in ten regions that range from some of the nation’s largest metropolitan areas (Chicago, Los Angeles, the San Francisco Bay Area and New York) to mid-sized regions (Buffalo, Pittsburgh, New Orleans, the Twin Cities and Portland) to the rural region of Thunder Valley Pine Ridge Reservation in South Dakota. In each region, partnerships were built from existing relationships among organizations that are working to solve different pieces of the health equity puzzle. Some of the partnerships include representatives of health departments or other public agencies while others include non-governmental organizations. Some are focused on a particular challenge, such as fair and affordable housing or transportation equity while others are tackling intersectional problems facing their neighborhood, city, county or region.
Through the Planning Exchange’s multiple convenings, workshops and forums with experts over the past year, several common priorities emerged:
Centering race in discussions about how to challenge enduring structures
Connecting public health officials and planning practitioners to promote more informed decision-making
Bringing together community organizations, policy and planning groups and government agencies in critical dialogue to build consensus on planning for equity and health
Understanding the critical role of the region as the place where various levels of government decision-making converge
Embracing opportunities to build networks across issue areas and political boundaries to promote health and wellbeing
Conversations that were geared toward broad topics -- such as inclusive engagement, access to power, policy implementation and the need for more resources to effect change -- led to the conclusion that structural racism and white dominance are power relationships that undermine health equity. This realization encouraged participants in the Planning Exchange to identify actionable strategies to decentralize power and to more thoughtfully navigate relative power and privilege in locally relevant ways in each of their work plans.
The exchange between health practitioners, urban planners, community advocates and government officials fostered an environment in which participants were able to connect the dots between health policy and urban planning. These connections helped build consensus on how to better address issues of health and equity, which led to a greater understanding that many drivers of health inequity operate at a regional scale. Interrelated challenges such as housing, transportation and climate change require networks that operate across issue areas and political boundaries.
From these conversations, each partnership shaped strategies and work programs that addressed fundamental challenges to health and equity within their regions:
Buffalo -- Greater Buffalo Niagara Regional Transportation Council, LISC Buffalo, and PUSH Buffalo
Advancing an equitable transit-oriented development process through internal organizational training around racial equity and meaningful partnerships with communities of color
Chicago -- Chicago Department of Public Health, Illinois Public Health Institute, and Metropolitan Planning Council
Integrate health and racial equity impact assessment into Chicago’s citywide planning process, and develop recommendations to improve health and equity outcomes via zoning and land use policies
Los Angeles -- Alliance for Community Transit, Community Power Collective, and LA County Department of Public Health PLACE program
Examining budgetary prioritization by LA Metro to promote community-led reinvestment into alternatives for policing and opportunities for better transit
Multnomah County, OR -- Multnomah County Department of Health
Convening public health and transportation officials to coordinate policy, strategy and funding for safer street design and reducing traffic fatalities, especially in communities of color
New Orleans -- Louisiana Fair Housing Action Center and Operation Restoration
Organizing for legislative and administrative policy to improve housing access and health outcomes for people with criminal records and eviction records, and building a network to support people impacted by incarceration
New York-New Jersey-Connecticut Metro Region -- Regional Plan Association and Make the Road
Advocating for Housing Opportunities for All from a health and racial equity framework
Centering undocumented people to ensure participation in available programs
Supporting ADU legalization and ‘good cause’ eviction legislation
Pine Ridge Reservation - Thunder Valley Community Development Corporation
Developing and enhancing Regional Equity Initiative to create and implement a vision for addressing systemic poverty and eliminating health and economic disparities on the Reservation
Pittsburgh - Pittsburghers for Public Transit and Hill District Consensus Group
Researching and advocating for land use policy connected to transit improvements based on engagement with transit riders
Housing Pittsburgh’s vulnerable populations to promote a built environment more conducive to health
San Francisco Bay Area -- SPUR and Urban Habitat
Analyzing parking and developing databases to support advocacy efforts to pass a regional employer parking fee to manage parking supply
Funding transit and active transportation in under-resourced communities.
As each region pursues its own distinct path to achieving greater health equity, the members of the Planning Exchange provide constructive feedback and support based on what has already been done in other regions of the country.
It is not a copy-and-paste model, but rather a basis for finding innovative solutions to health equity challenges that center around the same core issue of unequal representation and access.
In a similar vein, this paper offers a framework to help organizations and partnerships take the next step towards health equity for all. It draws on two years of dialogue within the Planning Exchange, distills relevant research, uses case studies to show how other regions have addressed similar challenges, and provides resources for further investigation.
Several approaches to urban health call for practitioners to map out the multiple scales of policy, governance and socioeconomics that shape an individual’s health outcomes, ranging from neighborhood conditions to structural forces such as racism. A Conceptual Framework for Urban Health, developed by Galea et al. (2006), illustrates how the different scales at which health is determined relate to one another and where practitioners can influence outcomes. This framework calls for practitioners to consider both the health outcomes and the social determinants that influence outcomes in their work. A model focused on planning, American Planning Association’s Metrics of Planning Healthy Communities, offers a clear set of categories that influence health, such as environmental exposures, and offers indicators and potential policies to consider in addressing the challenge.
The diagram below builds on these frameworks with both learnings from the Planning Exchange and research on what has been working elsewhere in the United States. It provides a way for organizations and partnerships to confront the social, economic, and political structures that impact health equity in an intersectoral way. This framework uses the following scales of intervention:
Programs that target specific determinants of health, such as housing, education, air and water quality, etc.
Holistic place-based strategies that address multiple determinants of health in a neighborhood, district or municipality
Multi-disciplinary regional strategies that promote health and equity across multiple jurisdictions with tools such as regional alliances and infrastructure planning
Organizing to shape national and global policies by connecting local experiences to larger networks and movements for policy change
Working towards mindset shift and culture change by addressing ubiquitous forces such as racism, classism or xenophobia as an integral part of the work
The following describes each of these levels of intervention, illustrating each with a case study that features local, innovative health equity practices that are occurring in regions of the country that are not represented in the Planning Exchanges. For Exchange participants, the examples may provide ideas or inspiration for how to integrate some of these approaches into the health equity work plans they have taken on. For other regions, which may just be beginning or thinking about this work, these case studies may help them identify their own pathway to achieving greater health equity.
Programs Targeting a Determinant of Health
This level of intervention offers the most direct way to address a specific cause of health inequity. According to the Centers for Disease Control (CDC), social determinants of health are the conditions in the environments where people are born, live, age, learn, work, play and worship that affect a wide range of health, functioning and quality-of-life outcomes and risks. The CDC groups these determinants in five categories: health care access and quality, economic stability, education access and quality, neighborhood and built environment, and social and community context. Many Planning Exchange participants have already undertaken initiatives at this scale of intervention by conducting research around an issue and building networks to advocate for change. Such programs are intended to target a specific problem that has been shown to impact people’s health and lives, such as a high rate of motor vehicle accidents or a high number of household evictions.
HomeWorks Trenton demonstrates how a non-profit can provide targeted services that improve immediate health outcomes while addressing education disparities in marginalized communities, a key determinant of health inequity.
Glenn Beltz
Trenton, NJ
HomeWorks Trenton is a non-profit whose mission is to “inspire and equip young women from marginalized communities to achieve their potential and positively transform the world around them by providing a supportive and educational residential environment.” The organization provides a boarding and afterschool program for high school girls residing in the Trenton area for the duration of the school year. Students attend school during the day five days a week and eat their meals, study, participate in group activities, and sleep at the HomeWorks site.
HomeWorks is working towards improving health equity in the Trenton community by supplementing an education system that was “built to deny students’ basic health needs,” according to an interview conducted by RPA with HomeWorks co-founder and executive director, Natalie Tung. Tung further remarks: “How can kids come to school to listen and learn if they are not given the space to deal with trauma that stems from structural racism and injustice, from lead poisoning or incarceration?”
Both of these circumstances and many others are, unfortunately, a reality for many Trenton residents. Trenton’s public schools do not have the capacity to combat these health-related issues and others, which have become chronic in the community. To this end, HomeWorks bridges educational attainment with the basic health amenities that students need at home to improve their health, such as providing wholesome meals and engaging workshops on sexual health and self-care. As a result, HomeWorks’ students show higher rates of achievement: the organization boasts a 93% attendance rate compared to the 70% average in Trenton public schools, and a median GPA of 2.7 compared with the Trenton public school median of 1.3. By improving students’ academic success, self-esteem, social-emotional skills and sense of leadership, Homeworks better positions the girls who participate in the program to secure the same personal, academic, and economic standard of wellbeing as their counterparts in more well-resourced regions of the country.
An intervention at this scale can be most effective when…
There is an established connection between a specific problem and health outcome
-- e.g. students who do not eat a healthy breakfast at home before schoolThe problem is measurable by one specific metric
-- e.g. a survey can ask teens what they eat for breakfast at home and their interest in having a healthy breakfast at school
The target demographic can be described precisely
-- e.g. high schoolers eligible for free-and-reduced lunchYour organization/agency already works with the target demographic and can address the issue with the help of a partner
-- e.g. a youth organization that partners with the local school district
Holistic Place-Based Strategies
This level of intervention begins to address multiple upstream health determinants usually manifested at the neighborhood or municipal scale. Some of the issues Planning Exchange participants are addressing, such as housing quality and affordability, access to public transit, and public safety, can achieve better outcomes through holistic place-based strategies. These causes are interrelated and difficult to disentangle, so place-based strategies are ideal for understanding and addressing the multiple factors that influence a community’s health. Both urban planners and community organizations often operate at this scale and are in a unique position to design multi-dimensional strategies that bring together residents and institutions. Addressing multiple problems simultaneously is a complex process, however, and effective partnerships require long-term commitments, strong leadership, and often rely on consultation with outside experts. A government agency, or a large institution such as a foundation, business partnership or labor council, is often in the best position to marshal the necessary resources.
Denver, Colorado is one place where a once singular-purpose city agency has evolved to embrace a holistic strategy that enables neighborhoods to address multiple determinants of health.
Larry Johnson
Denver, CO
The Denver Housing Authority (DHA) has forged an integrated approach to health equity. It has evolved from a traditional housing authority that managed the city’s public housing to one that addresses the comprehensive needs of city neighborhoods. During an interview conducted by RPA, the executive director of DHA, David Nisivoccia, commented on the importance of the“synergy” that exists between the multiple forces impacting health equity. He remarked that many of the issues impacting Denver residents cannot be appropriately addressed without a“collective perspective” that mobilizes all government agencies and not just those involved in housing or other single issues.
In one effort, DHA has paired its efforts to expand affordable housing opportunities with efforts to supply state of the art, affordable food options in proximity to that housing. As part of the larger HOPE VI redevelopment efforts in the Mariposa Community, DHA worked with the Youth Employment Academy (YEA) to open the Osage Café, a social enterprise designed to provide healthy and affordable food and workforce development opportunities to the community. The Osage Café offers a culinary academy and paid internships to youth to support job development in the restaurant industry, learning skills in food preparation, customer service, sourcing and ordering food, and preparing food grown in the nearby gardens.
DHA’s second commitment to the neighborhood was to introduce a small grocery store carrying affordable household staples and fresh produce. To accomplish this, DHA and YEA partnered with Choice Market to open the young Denver-based company’s second grocery store with wholesome, affordable food options and prepared meals in the new DHA headquarters in Mariposa.
The decision to open the new supermarket in this location is both a symbolic and practical choice, as the neighborhood of Mariposa is historically one of Denver’s most underserved. The market is staffed by local students enrolled in DHA’s Osage Café youth culinary program. These students gain important skills and training in healthy food sourcing, preparation and packaging, retail sales, and marketing. This builds on prior DHA investment in the neighborhood by improving transit and funding cultural centers. The partnership with Choice Market allowed the holistic vision of health and housing to come together in a new market—recently opened in the Sun Valley redevelopment—called Decatur Fresh Market. Decatur Fresh Market is operated and staffed by the Youth Employment Academy. Decatur Fresh will implement similar academies and internships for both youth and adults in customer service and retail management to further develop career opportunities for residents living in the neighborhood. Each market is customized with produce and meals that cater to the specific cultural and nutritional needs and desires of each community.
An intervention at this scale can be most effective when…
The focus is on a well-defined place, usually a neighborhood, district or municipality
-- e.g. the catchment area of a community organizationSuccess requires progress on multiple, interrelated issues that are measurable through different metrics
-- e.g. indicators or an index that capture health, economic and quality of life conditions such as unemployment, housing cost burdens, asthma rates, accessible parks, etc.
The target demographic is defined by the geographic boundaries of the place
-- e.g. all low-income families living within a particular ward or community districtYour organization/agency can address the issue alone or with the help of a well-resourced partner
-- e.g. a local hospital with the capacity to open a satellite health center in closer proximity to the population in need
Multi-Disciplinary Regional Strategies
Because job markets, housing markets and infrastructure systems operate on a regional scale, both targeted programs and place-based strategies can be more effective when connected to region-wide partnerships. The premise of the Planning Exchange is that health equity can be a compelling and effective approach for mobilizing actors across functional silos and political boundaries. By establishing clear health and equity metrics to inform policies, cities and regions will be more likely to fund projects and programs that will lead to healthier regions. The prioritization of health equity policies can be realized in a number of ways, including comprehensive planning that uses health equity metrics to allocate resources, or environmental review processes that are attuned to the unequal consequences of various interventions for certain localities, such as deciding where to put a public bus depot. While this level of intervention sets up municipalities and regional entities to better invest resources in order to improve health, they still require community expertise and buy-in and the resources to implement them effectively.
The Puget Sound region offers a model for how a multi-jurisdictional planning entity can put greater emphasis on equity and health in plans that help drive government investment.
Max Pixel
Puget Sound, WA
The Puget Sound Regional Council (PSRC) is a leading example of a council of governments that incorporates equity and health as part of its mission. PSRC produces regional plans, policies and programs that include housing, economic development, watershed and stormwater planning as well as growth management for the area of Washington State that includes Seattle, Tacoma, four counties and nine tribal governments. A workplan for a Regional Equity Strategy states that “PSRC will work with the Equity Advisory Committee (EAC) to co-create a Regional Equity Strategy. The Strategy will seek to improve outcomes for marginalized communities and how the agency operates internally,” and calls out its long history of racism with a responsibility to advance racial equity.
To promote health equity, public health officials have seats on PSRC’s advisory boards. It has disseminated a Planning for Whole Communities Toolkit to help local jurisdictions connect the dots between planning and health, equity and sustainability, plus separate toolkits for Healthy Community Planning and Equitable Community Engagement. In addition, the region’s VISION 2050 plan has specific policies promoting health and healthy communities. PSRC was also recognized for launching one of the most successful initiatives funded by the federal Partnership for Sustainable Communities, and specifically for a governance structure that promoted equitable representation and outcomes.
An intervention at this scale is recommended if…
The scope of the problem extends beyond neighborhood or municipal boundaries
-- e.g. inaccessibility to a public transit network that provides access to jobs and opportunities throughout a metropolitan areaThe issue is measurable at multiple geographic scales
-- e.g. number of quality jobs that can be reached within an hour by public transit from all neighborhoods within a metropolitan area, as well as within the region as a whole
The target demographic is broad and intersectional, cutting across geographic and demographic boundaries
-- e.g. all residents and businesses in the region who would benefit from improved transit that aligns with housing and economic development policiesYour organization/agency can address the issue with the help of multiple well-resourced partners
-- e.g. regional transit authorities, municipal agencies and neighborhood organizations must have the budget, capacity, and willingness to plan and execute transit investments that serve those in need
Organizing to Shape National and Global Policies
Throughout the Planning Exchange, participants have remarked how national and global policies can make an enormous difference to communities, planners, and policy makers seeking to create healthy and equitable neighborhoods. The 1970 Clean Air Act offers an example of how federal policy can improve health. According to the UN Environmental Programme, the Act is responsible for preventing over 230,000 early deaths by 2020. Connecting with communities within and across regions presents an opportunity to build national networks and movements to push for more significant changes at the federal level, which can be implemented locally for more immediate and visible effects. It can also be empowering to community participants, and provide opportunities for peer-to-peer learning.
On the Gulf Coast, The Deep South Center for Environmental Justice improves the lives of vulnerable communities through sharing knowledge, community training, and organizing to shape environmental policy.
Roy Luck
Gulf Coast
The Deep South Center for Environmental Justice is the nation’s very first environmental justice center. It was founded in 1992 to improve the lives of vulnerable communities in the Gulf Coast Region of the United States. From traumatic climate events such as Hurricane Katrina in 2005 to manmade disasters such as the Deepwater Horizon oil spill in 2010, the Gulf Coast is becoming an increasingly delicate ecosystem to manage and restore for both the people and the wildlife that depend on it. The Deep South Center is credited for being the first environmental justice center to work with a Historically Black College or University (HBCU). Through its “communiversity model,” the Center has urged university professors and students to conduct research on locally relevant environmental topics that directly benefit the community. The model also inspires young people of color to pursue environmental justice careers by training them on how their knowledge can impact their region.
Since its founding almost 30 years ago, the Deep South Center has published research on various topics related to environmental justice, such as how disproportionate air pollution exposure impacts African-American communities, the benefits of regulating city power usage, and conducting flood risk analyses that aid the most vulnerable communities. The Center has developed community training modules on hazardous worker health and safety, and has collaborated with multiple universities and other community-based organizations to form consortiums on climate change and equity. The Deep South Center has even connected with international communities in South Africa and Chile that are marginalized on a global scale in the fight for environmental justice.
An intervention at this scale is recommended if…
The scope of the problem is at the national or global level
-- e.g. fortifying cities against the effects of climate changeThe issue is measurable, but highly complex
-- e.g. extensive data, surveys, technologies and reporting standards are necessary to begin to grasp the multi-faceted nature of the issue at hand
The issue affects almost everyone to some degree
-- e.g. people living in coastal areas or regions that are susceptible to storms or extreme temperatures are inclined to move to safer/more livable regions of the worldYour organization/agency cannot address the issue without a significant number of well-resourced partners who are well-aligned in their beliefs and values
-- e.g. multiple partnerships and agreements made between national, regional, and local entities to fundamentally change economic and human behavior related to climate change
Working Towards Mindset Shift and Culture Change
One of the most important insights from the Planning Exchange is the importance of focusing intentionally on ideological and cultural change. Most political frameworks tend to discuss structural forces which inhibit health equity as permanent “enduring structures” that are immovable. These structues are not immovable, however, and improving health equity in some cases necessitates a direct upheaval of systems that persistently limit creative solutions to longstanding issues that seem permanent. Not challenging these structures to widen the panorama of what is politically possible and necessary to make changes is disempowering and dehumanizing for those most affected by them. Centering race in conversations around planning and governing, elevating indigenous voices and sovereignty, and reimagining land tenure are some of the ways practitioners can more accurately target root causes and redefine what is possible. This dimension ought to be incorporated into missions and strategies at any scale of intervention: from targeted programs to neighborhood, regional and national campaigns. This scale of intervention reminds us that “healing” is the precursor to “health.” In other words, actively rewriting narratives to engage voices that have consistently been ignored in the health equity discourse is a precursor to holistic, lasting change with universal impact.
The Healthy Regions Planning Exchange is taking an intentional approach to change the mindsets that have -- and continue to -- cement health inequity in place.
Healthy Regions Planning Exchange
Each of the ten regional partnerships participating in the Planning Exchange is working at one or more of the four levels of intervention described in the framework above. While the focus is different for each partnership, they are all incorporating specific actions to help change the dominant narrative that impedes change. Through their interactions within the Exchange, these organizations are developing the knowledge, relationships and tools to make these actions more effective and broaden their influence.
In the Bay Area, Los Angeles, Buffalo, and New York regions, programs that target specific barriers to health equity, including housing precarity, displacement and underfunded transit, are being used to shift the predominant dialogue. These regions are working to shift mindsets through training sessions and public campaigns that counter misinformation and broaden coalitions.
In the Twin Cities, Pittsburgh, New Orleans, and Pine Ridge, holistic strategies for neighborhoods and cities are helping residents tell their stories to a wider audience. These regions are working to shift mindsets through research, publications, and events to humanize the ways in which power structures perpetuate health inequity in BIPOC communities, as well as working to empower community members to influence and enact change themselves.
In Chicago and Multnomah County, multi-disciplinary regional strategies are restoring the historic link between urban planning and public health. These regions are working to shift mindsets by showing the effectiveness of building trust and alliances while leveraging partnerships to address the vestiges of systemic racism in our built environment.
An intervention at this scale is recommended if…
The scope of the problem is at the national or global level
-- e.g. racial or ethnic discriminationThe issue is immeasurable due to its complexity
-- e.g. everyone is touched and affected in one way or another
The issue is rampant and omnipresent, but is not necessarily intuitive or well understood
-- e.g. implicit and explicit racial biases persist in every facet of lifeYour organization/agency can play an important role as part of a larger movement for systemic change
-- e.g. shifting language and mindsets across all public and private institutions
We dedicate this research investigation to Arlene Rodriguez, our mentor, consultant, and friend. Arlene’s work, passion, and influence will continue to remind us that we must first know our destination before setting out on our path.
Next Steps
Ultimately, the Planning Exchange has been a space to rouse and inspire fellow participants by connecting local experiences to larger networks and movements for policy change at a national level.
As the Exchange continues to mature and accomplishments grow, we will present our own case studies to inspire other metropolitan areas to advance racial justice and health equity through urban planning.
We hope Planning Exchange participants, as well as entities in other regions, can situate their own work into these levels of intervention and strategize how to lead or support efforts at other scales to improve health equity for all. For participants already operating at more than one scale, this framework can help them identify where to deepen, extend, and improve their work. Central to this process will be a clear analysis of health, equity, and governance challenges that are occurring in the regions, and an understanding of potential avenues to drive lasting, meaningful, and transformative change.
Acknowledgements
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